First there's the pain. Then comes a prescription for an opioid: OxyContin, Tylox, Percocet, Roxicodone, among others. But what often follows is a vicious cycle of tolerance, increased dosages, abuse, and addiction.

Users say it gets into your bones.

Nationwide, the opioid epidemic is out of control. Deaths from prescription-opioid overdoses tripled between 1999 and 2008, according to the Centers for Disease Control and Prevention; there are now over 15,000 such deaths annually, more than from heroin and cocaine ODs combined. In a 2010 report, the White House acknowledged that addiction to opioids is the "fastest-growing" drug problem in America.

In Massachusetts, the problem is particularly acute. New Englanders entered substance abuse treatment facilities in 2009 for opioids at a rate twice as high as the national average, according to the Drug Abuse Warning Network. While the treatment admission rate for heroin declined nationally, admissions for opioids increased by 430 percent.

The effect on the Commonwealth has been devastating. Between 2002 and 2007, 78 Massachusetts soldiers died in Afghanistan and Iraq. During the same period, more than 3200 Massachusetts residents died of opiate-related overdoses.

This catastrophe is corporate in origin, professionally manufactured and marketed. And at its roots are complicated questions about how doctors treat chronic pain, how drug companies like Connecticut-based Purdue Pharma misled those doctors, and why federal regulators didn't move more quickly to stem the tide of addiction.

Even as the death toll mounted, Purdue raked in billions for its flagship pain medication OxyContin — despite federal indictments that resulted in hundreds of millions paid out in legal judgments, following a highly publicized 2007 court battle. Nor did the legal outcome slow the drug down — Purdue's Oxy profits soared from $800 million in 2006, the year before the federal settlement, to over $3 billion in 2011.

While Canada has pulled OxyContin from its shelves entirely, and many US physicians are begging the Food and Drug Administration to take more restrictive measures, local attempts to stanch the flow of Oxy from pharmacies to the streets have been slow and protracted. It wasn't until August 18 of this year that Governor Deval Patrick signed legislation requiring doctors to register with a program that will track patients and their prescriptions, sounding an alarm if individuals appear to be abusing the system to obtain drugs.

Massachusetts' drug-monitoring bill is just another weapon in a long war — a war that started when Purdue waged an aggressive marketing campaign to place a new version of an old drug in doctors' hands.

"[Oxy] changed lives overnight," says AFL-CIO president Steve Tolman, a past chair of the state's Commission on OxyContin and Heroin. "It turned good people into sick people, and the pharmaceutical industry doesn't want to bear any responsibility."

PORTENOY'S COMPLAINT

In a way, the pill proliferation of today started in 1986. That was the year Dr. Russell Portenoy, chair of the Department of Pain Medicine and Palliative Care Department at Beth Israel Medical Center in New York City, published a groundbreaking study that supported the long-term use of opioids for treating noncancer pain.

Until then, doctors had been leery of prescribing opioids for long-term pain management, or in cases other than palliative care for the dying. They knew that the pain-relief that opioids provided came with a price: addiction.

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